Tag: Death And Dying

A divisive national debate over whether dying patients should have the power to end their own lives will sweep into Maine this week when the Republican-controlled state Senate begins to consider so-called “death-with-dignity” legislation.

Sen. Roger Katz’s bill, which the Republican from Augusta says the Senate could take up as early as Monday, is modeled after legislation passed in Vermont two years ago that allows physicians to provide lethal doses of medication to terminally ill patients who want to hasten their death. Katz and other supporters say those who are suffering should be free to end their lives on their terms.

“Why not have the right to say, ‘I want to go, I’ve had it’?” said 85-year-old June Wagner, whose daughter died in 2012 at the age of 54 after suffering from ovarian cancer. Her daughter lived in Washington state, which has such a law, and obtained a prescription to end her own life, but Wagner said she doesn’t know if she ultimately used it.

Maine would become the sixth state in the country with such a law if Katz’s bill passes this year, but it faces an uphill battle. Lawmakers here have repeatedly rejected similar measures and voters defeated a ballot referendum on the issue in 2000.

It has been met with fierce opposition from some religious and medical groups, including the Maine Medical Association and the American Nurses Association of Maine, who say lawmakers should focus instead on ensuring that all residents have access to proper health care that can make them comfortable in the final months of their lives. Others say they fear patients will feel the need to end their own life because they believe they’re a burden on their families.

Suzanne Lafreniere, director of the office of public policy for the Roman Catholic Diocese of Portland told lawmakers earlier this year that a person’s life must be protected “at every stage and in every condition.”

“A law permitting assisted suicide would demean the lives of vulnerable patients and expose them to exploitation by those who feel they are better off dead,” she said in her written testimony.

Brittany Maynard thrust the issue back into the national spotlight last year she ended her own life just before her 30th birthday in Oregon, the first state to legalize the practice. Maynard, who was dying of brain cancer, advocated for aid-in-dying laws in videos shared widely online.

Kandyce Powell, who opposes the bill and is executive director of the Maine Hospice Council, said she believes the proposal wouldn’t resurface so frequently if more people in Maine had proper access to end-of-life care.

Vast rural parts of the state lack hospice or palliative care that can ease a person’s suffering in the final stages of their life, Dr. James VanKirk, medical director of palliative care services at Eastern Maine Medical Center.

“I am not against people having choice. That’s what we’re all about in this country,” VanKirk said. “But I think if we’re going to give people this kind of choice … we need to make sure that they really have a choice. We need to make sure that they don’t feel like they are in a situation where there is only one option.”

Katz agreed that expanding access to health care is crucial, but palliative care may not make things bearable for everyone, he said. He stressed that his proposal includes many safeguards, including requirements that a second doctor has confirmed that the patient has a limited time to live.

He’s hopeful that the national discussion and the increased awareness of the issue over the last year will help propel his bill into law — if not this year, sometime soon.

“There are some people who have religious objections or other moral objections and I respect that,” Katz said. “But I think that most people have an open mind and are waiting to hear the debate.”Complete Article HERE!

Even after the conversations are held and legal documents completed, reaching acceptance that a person is dying is a difficult path for the individual who is ill as well as for their family members.

Many recent news stories have focused on right-to-die issues — what options might we want, and what control can we exert, as we approach the end of life? When death is sudden and unexpected, there are few choices, and if there has been no preparation for this moment, events will unfold as medical and emergency staff see fit. But when illness is chronic or prolonged, or when pain, frailty and old age impact the quality of life, there are measures we can take to have our wishes respected, to share those wishes with others, and to request a dignified, comfortable death.

An NPR story last year examined why some health care providers are hesitant to discuss end-of-life measures, even with seriously ill patients. There are many reasons: not enough time; not wanting the patient to give up hope; discomfort with the topic. One suggestion has been to initiate a physician-patient discussion about end-of-life issues automatically each year. Not all patients welcome the discussion, but sometimes the increased feeling of control actually can make patients with long-term illnesses feel better. They can decide, for example, to refuse certain medical treatments. They can decide if they want “heroic measures” — feeding tubes, CPR, ventilators, defibrillators — to prolong their lives when a desirable quality of life (however one may define that) might not be possible.

Making these decisions isn’t easy, and for family members and friends, accepting these decisions may be challenging, even traumatic. In our recent NewsHour columns, we talked about Advance Directives, hospice care, and other measures designed to make — as much as possible — the end of life a more peaceful transition for the patient. But watching someone you love slip away can be so overwhelming that it is instinctive to want to do everything possible to keep that person alive, even against their own wishes. How do you accept letting go?

Where to begin

Sometimes we hear from our clients that the person they are caring for wants to discuss these matters, but they or their family members are reluctant to face the issue. Below are some ideas to help begin the process to help clarify decisions about the end of life. Experts advise that you begin by thinking and talking about values and beliefs, hopes and fears. Consult with health care practitioners when you need more information about an illness or treatment.

Consider first the questions below:

What makes life worth living?

What would make life definitely not worth living?

What might at first seem too much to put up with, but then might seem manageable after getting familiar with the situation and learning to deal with it?

If you knew life was coming to an end, what would be comforting and make dying feel safe?

What, in that situation, would you want to avoid?

How much control is important for you to have when facing a terminal illness?

Then, if you have the opportunity, and before a loved one is incapacitated, try to explore these more specific questions:

Whom do you want to make decisions for you if you are not able to make your own, on both financial matters and health care decisions? The same person might not be right for both.

What medical treatments and care are acceptable to you? Are there some that you fear?

Do you wish to be resuscitated if you stop breathing and/or your heart stops? What if there is no hope for full recovery?

Do you want to be hospitalized or stay at home or somewhere else if you are seriously or terminally ill?

How will your care be paid for? Have you overlooked something that will be costly at a time when your loved ones are distracted by grieving over your condition or death?

Will your family be prepared for the decisions they may have to make?

Write the responses down, and share with family members. To formalize the process, you can complete an Advance Directive and POLST (Physician’s Orders for Life-Sustaining Treatment). Both documents can be revised at a later date if you wish.

A note: This process is not appropriate for everyone. There may be historic, religious or cultural differences within families that affect their willingness to discuss these deeply personal matters. If it makes sense to bring up these topics, do so. If it is not something that your family is comfortable with, you might not be able to get the answers you seek. You can try again at a later time — or perhaps not at all. Families have their own dynamics, and for some, this discussion simply may not be achievable or desirable. In the case of a serious illness, events will unfold as they may. That is also a choice, and must be respected.

Letting Go

Even after the conversations are held and legal documents completed, reaching acceptance that a person is dying is a difficult path for the individual who is ill as well as for their family members. The person who is ill doesn’t want to cause grief. She may feel there is unfinished business within the family — a reconciliation not completed, an “I love you” never stated out loud. He may be fearful of pain, of the loss of control, of the loss of dignity. And of course family members share these fears. They may dread the grief or fear of losing this critical person in their lives. They may want to attempt the very measures — the heroic measures — that the individual specifically stated he or she does not want.

Despite the pain of grief for those we love, being able to let them go is not about our needs, nor about the physician’s need to try to heal even in the face of impossible odds. It is about what our loved ones need and want to reduce their suffering and help them die in dignity. When those wishes have been talked about, and when they are in writing, a family has the comfort and assurance that they are doing the right thing if they are asked to give permission to accept comfort measures instead of life-sustaining interventions.

A natural process sometimes occurs as an illness progresses. As death nears, many people feel a lessening of the desire to live longer. Some people describe a profound tiredness. Others may feel they have struggled as much as they have been called upon to do and will struggle no more. A family’s refusal to let go can prolong dying, but cannot prevent it. Dying, thus prolonged, can become more a time of suffering than of living.

Family members and friends may experience a similar change. At first, we may adjust to managing a chronic illness, then learn to accept a life-limiting illness, then accept the possibility of a loved one’s dying. Finally, we may see that dying is the better of two choices, and be ready to give the loved one permission to die. The dying person may be distressed at causing grief for those who love them, and, receiving permission to die can relieve their distress. There is a time for this to happen. Before that, it feels wrong to accept a loss, but after that it can be an act of great kindness to say, “You may go when you feel it is time. I will be OK.”

At the time a person is near death, sometimes touch is the best communication. Gentle stroking of a hand or a cheek, and quietly reassuring the person that you love them and that you will be all right is perhaps the most compassionate way to ease your loved one on his journey. In a situation where you are not present at the time of death, forgive yourself and know that you did the best you could to make the final hours or weeks of life peaceful and meaningful.

Grief

Each individual grieves in his or her own way and for an unpredictable amount of time—there is no “correct” way. Grief affects us emotionally, physically and spiritually. There is a deep understanding that nothing will ever be the same. Grief is most acute when someone dies or shortly thereafter, but there are also the effects of “anticipatory grief” and what is sometimes called “ambiguous loss.”

When someone has a long-term illness such as terminal cancer or Alzheimer’s or Parkinson’s disease, we may begin a grieving process long before the person passes away. Particularly when an illness causes cognitive or memory decline, we grieve the person who used to be. They were our partners, our siblings, our parents. We remember their personalities, their intelligence, energy, talent, humor. They were our best friend, companion, adversary, advisor or confidante. As those characteristics fade with increasing illness, we start grieving their loss. The body may be there, but the person has changed irrevocably. It may have been difficult, frustrating and exhausting to care for the individual, and sometimes, caregivers see death as a relief. As a consequence, for many family caregivers, there is an extreme feeling of guilt over that relief. This is not an unusual reaction, but if the emotions persist, counseling or support groups may help you get through the conflicting and troubling feelings.

For other people, there is a delay in feelings of grief, or the feelings may be buried or expressed in different ways — withdrawal, anger, escape through drugs or alcohol, or intense involvement in work. Grief reactions may be unexpected and waves of painful memories may assault you at unpredictable times. The anniversary of a person’s death or other important dates can be particularly tough. However the process unfolds, take care of yourself, cry when you need to, seek solitude if that helps, and try to give yourself the space you need to reach an even keel.

While the passing of time will not erase feelings of loss, the intensity will ease somewhat as months and years go by. If you find it too difficult to move on with your life, you may be facing situational depression. Find time to talk with a grief counselor or attend a grief support group (often available from hospice). It is very important to take good care of — and be kind to — yourself. The organizations and resources listed below, or those in your personal or faith network, may also be able to help as you move through this profound experience — one we all must face at some time in our lives. One that makes us human.Complete Article HERE!

Allows doctors to provide lethal drugs to patients with less than six months to live

In an emotional vote on Thursday, the California Senate advanced a controversial proposal allowing terminally ill people to seek life-ending medication.

Modeled on a law first enacted in Oregon in 1997, Senate Bill 128 would permit doctors to provide lethal drugs to patients with less than six months to live. The measure passed 23-14, over passionate objections from Republicans who argued it devalues life.

The deeply personal debate lasted for more than an hour-and-a-half, as senators shared stories of lost loved ones and their own struggles with suicidal thoughts. Democrats urged their colleagues to support a “compassionate” end-of-life option that lets people die in peace.

“I was 17 when my vibrant young mother ended a three-year struggle with metastatic cancer, and it was frankly brutal,” said Sen. Lois Wolk, D-Davis, who authored the measure.

“Her suffering was prolonged and unbearable – for her, certainly, and also for her family,” she said. “It does not have to be this way.”

While Washington and Vermont have since followed Oregon in legalizing assisted death, numerous proposals from California lawmakers have fallen short over the years in the face of vocal concerns from doctors, the Catholic Church and disability rights groups. The last major effort, by then-Assembly members Patti Berg, Lloyd Levine and Fabian Núñez in 2007, was never brought to the floor for a vote.

Proponents were buoyed this time, however, by the story of Brittany Maynard, a Bay Area woman with brain cancer who gained national attention last fall when she moved to Portland to take advantage of Oregon’s law. Her widowed husband, Dan Diaz, and mother, Deborah Ziegler, sat in the back of the Senate chamber on Thursday with a portrait of Maynard.

“The Senate vote, I feel, is an affirmation of what Brittany started,” Diaz said at a news conference following the vote. SB 128 “will not lead to more people dying. It will lead to fewer people suffering.”

Choking back tears, Ziegler said she felt Maynard’s “presence swirling around, her energy, her love.”

“I am so proud of her, and I am so proud of California senators today,” Ziegler added.

Sen. Cathleen Galgiani, D-Stockton, framed the vote as an ethical responsibility for the Senate. As medical science allows doctors to prolong life, she said, patients and their families are faced with more difficult choices.

“This bill gives guidance to someone who’s dying … about whether everything has been considered,” she said. “It will give loved ones the ability to move to their next life without guilt, without shame, and it will give loved ones the chance to say goodbye.”

Nine Republican lawmakers rose to speak against the bill. Some opposed it on religious grounds, saying the state should not make life or death decisions. Sen. Ted Gaines, R-Roseville, suggested it violates the Declaration of Independence.

“It is a total inversion of (the government’s) purpose, to transform it into an instrument of death,” he said.

Sens. Sharon Runner, R-Lancaster, and Joel Anderson, R-Alpine, confessed to grappling with a desire to die during medical crises, and asked their colleagues not to give sick people a reason to give up.

“You bet I thought about suicide. You bet I did,” Anderson said, his voice wavering. “I don’t want to do anything that the state sponsors to strip hope and add guilt to our citizens.”

Urging his colleagues not to “sanitize” the discussion, Sen. Bob Huff, R-Diamond Bar, reminded them that many doctors believe assisting in a patient’s intentional death violates their role as healers. “Reality is this is aid in killing,” he said.

A major obstacle was cleared last month when the California Medical Association dropped its long-standing opposition because of provisions that would allow physicians with moral objections to opt out of the law.

Wolk thanked the CMA for providing guidance on bill language and pointed to numerous safeguards for patients, who must be assessed by two independent physicians, provide two written and one verbal request for the lethal drugs, and wait 15 days before a doctor writes a prescription.

“It must be an affirmative, conscious act,” Wolk said.

Disability rights advocates have led the campaign against SB 128, arguing that legalizing assisted suicide would put the elderly and other vulnerable Californians in harm’s way.

“This bill … tells people with disabilities who face a terminal diagnosis, that may well prove inaccurate, that there is no dignity in our lives,” Marilyn Golden of the Disability Rights Education & Defense Fund said in a statement. “Assisted suicide is dangerous, and we are going to bring that message loud and clear to every member of the state Assembly and the governor.”

SB 128 heads next to the Assembly, where supporters are hopeful that CMA’s neutrality will ease passage. Gov. Jerry Brown, who once trained to be a Jesuit priest, has yet to weigh in publicly on the proposal, but his office confirmed on Thursday that he spoke with Maynard by phone before she died.Complete Article HERE!

La Crosse is a small town in western Wisconsin, right on the Minnesota border. It has about 51,000 residents. And La Crosse has, over the past three decades, done something remarkable: nearly all its residents have a plan for how they want to die.

“One of our doctors recently told me that making a plan is just like taking blood pressure or doing allergy tests,” says Bud Hammes, a medical ethicist at Gundersen Health System, one of La Crosse’s two hospital networks. “It’s just become part of good care here.”

End-of-life care planning is not currently a routine part of medical care in the United States. Most surveys show that about a quarter of American adults have completed an advance directive, spelling out what type of treatment they would want in a medical crisis where they could no longer make their wishes known.

Making a plan is just like taking blood pressure or doing allergy tests. It’s just become part of good care here.”Americans don’t plan for death because health insurance plans don’t typically pay for that sort of planning, the way they cover blood tests or MRI scans. Medicare, which covers Americans over 65, certainly doesn’t pay for end-of-life care planning: when the Obama administration proposed such an idea during the 2009 health reform debate, it quickly spiraled into talks about “death panels” and “pulling the plug on Grandma.”

The dearth of end-of-life care planning in the United States often means that lives end in chaos, with families confused and overwhelmed trying to think through what their loved ones would want.

“It’s one of the most uncomfortable things,” says Donn Dexter, a neurologist in Eau Claire, Wisconsin, about a two-hour drive north of La Crosse. “The family can be so at odds, and the patient has not made clear what they want. I’ve seen families just torn apart by this, and their loved ones tortured with prolonged, futile treatment at the end of life.”

When La Crosse started talking about death in the mid-1980s, a few patients were annoyed. People who turned up at a physical and had a doctor ask about their end-of-life preferences were, understandably, confused.

“Patients were sometimes upset or anxious, like, ‘Why are you bringing this up? Is there something wrong with me?'” Hammes says. “There were lots of strong emotions and this sense that this was only for people at the end of life and dying. We had to work really hard to convince people we wanted every patient to have this discussion.”

But doctors kept asking, until patients got comfortable. And there were never any accusations of “death panels” or “rationing”: the program seemed to work because it was grassroots, rather than imposed by the government or some other large entity.

The story of La Crosse — and how its approach to end-of-life care is quickly, quietly spreading across the Midwest — gives some reason to be optimistic about the future of end-of-life care in America. It suggests that it is possible to move beyond death panels, and for doctors to have frank conversations with patients about how their life will end. The trick, it seems, is making these conversations feel like a natural part of the doctor-patient relationship, rather than a mandate imposed by a menacing bureaucracy. The only problem is this: for programs like La Crosse’s to work on a national level, the federal government is eventually going to have to get involved — and pay doctors for this type of service. Is that something America will ever be ready for?

“Situations where it wasn’t clear what was best”

La Crosse’s push to get its residents to talk about death began in the 1980s, when Hammes joined Gundersen to develop a curriculum for the moral quandaries that medical students would go on to face as doctors. He shadowed some students to get a sense of the issues they confront.

“What I witnessed with such frequency were situations where it wasn’t clear what was best, and the patient’s perspective would help resolve that question, but we couldn’t get that perspective,” he says.

Hospitals don’t know when patients will die. But they do know death will happen — and can plan for that.

As an outsider to the medical system, Hammes found this baffling. Some of these patients had been in the hospital’s care for decades. While it was impossible to predictwhen a patient would die, the hospital clearly knew, with great certainty, that all lives end. Yet there was no apparent planning for that moment.

Hammes suggested that the hospital start talking to patients about death. They started with a small group of 60 patients with kidney failure. They and their families talked about priorities in medical care and whether they would want to continue living if they lost awareness of who they were, or where they were.

“What we noticed is that as we had those conversations, the conflicts became less frequent,” he says. “The norm became the family saying, ‘We know what to do; we had a conversation.'”

The success of Hammes’s pilot encouraged Gundersen and the other hospital in town to expand the program to the entire city. They would work not just with patients who were facing imminent crisis, like the dialysis group, but with any adult in the system.

By 1995, 85 percent of La Crosse residents had an advance planning document on their record. In 2008, it hit 90 percent. These documents were effective: researchers foundthat among those who died, the care they wanted nearly universally aligned with the care they received.

All of this happened without political blowback. The movement to talk about death spread quietly, from doctor to doctor and patient to patient.

And, perhaps most surprisingly, the La Crosse conversations appeared to save money. The city has some of the lowest end-of-life spending in the country; people who die in La Crosse spend approximately 32 percent less than the average Medicare patient in their last six months of life, the Dartmouth Atlas of Health Care shows.

This suggests something broken about the way end-of-life care usually works: it is much more intense than patients desire. When patient preferences are known — as they almost universally are in La Crosse — people tend to select less aggressive courses of treatment. And this is what has earned the La Crosse model so much praise: it’s shown a meaningful reduction in health spending as a side effect of respecting patient wishes.

And that’s why there’s a now a movement to bring the La Crosse program to the entire state of Wisconsin.

“We want every adult to have the conversation,” says John Maycroft, who oversees policy at the Wisconsin Medical Society, a doctors’ advocacy group. “It’s about the conversation. And the document is of course important, but if everyone can have this conversation, we’d all be better for it. We could shift the culture in a big way.”

“Do you have thoughts about what you would want to happen?”

The name of the program La Crosse developed is called Respecting Choices. It’s essentially a script for having conversations about the end of life. The idea is to have patients talk about the type of care they would want if they could no longer speak on their own behalf, like after a serious car accident.

What makes Respecting Choices work is that it’s formulaic. It gives structure and steps to what is otherwise a difficult conversation — the type of conversation that medical school doesn’t prepare doctors to have. Those trained in the curriculum say having a script to follow is essential; they know exactly what information they need and how to get it. And they’re forced to practice, over and over again, until it feels like second nature.

I had Mia Morisette, an advance care planning coordinator for University of Wisconsin Hospital and Clinics, go through the script with me. In her distinctive Wisconsin accent, she started by asking me what I knew about advance directives — how they worked and why they were important. And she asked me to reflect on what I’d seen, in my own family, with the end-of-life experience going well or poorly.

A difficult conversation is guided by a script — making the interaction much less awkward

I told Morisette a bit about my grandmother who died in 2010. One of the things I remembered being stressful for family members was the notion of doing everythingpossible. There seemed to be a tremendous desire for everyone to walk away from the ICU thinking, “At least we did everything we could.” Sometimes that desire could override what was actually the best for my grandmother’s care. I didn’t want my family to have that type of burden, I told her.

Without knowing it, I had moved on to the next part of Morisette’s script: what I would want. Morisette had a very specific thing she wanted me to think about. I didn’t need to think about what I would do if I got a cancer diagnosis or found out I had a year to live. If that happened, we could revisit my options. Instead, she wanted me to think about a situation where I wouldn’t be able to make my care preferences known.

“Consider a situation where a serious car accident left you unable to communicate,” she said. “You’re receiving medical care to keep you alive, but there’s little chance you’ll ever recover the knowledge of who you are and who is around you. Do you have thoughts about what you would want to happen?”

I asked Morisette to define “little chance,” which she estimated to be around 5 percent.

Then I was stuck. I sat on the phone silent for a moment. Even as a reporter on these issues, I didn’t know what I wanted — generally, my hunch was to stop treatment with such long odds in my favor. But I also had a nagging voice wondering about that 5 percent chance.

Morisette told me this was all normal; this was the point of having the conversation in the first place — to have these thoughts, and to work through them. Most of her consultations usually take three or four visits to fully complete.

“It’s not all at once,” she told me about the process. “Sometimes it helps just to use the first conversation to get in the frame of mind.”

“We eventually want everyone to have this conversation”

Maycroft of the Wisconsin Medical Society started working on bringing the La Crosse model statewide in March 2013. Minnesota had done the same thing a few years earlier, to generally positive results. Minnesotans, in 2014, showed higher rates of end-of-life planning than the national average.

The Wisconsin program started small, with six hospitals piloting La Crosse’s model elsewhere in the state. Over two years it’s grown steadily, up to 23 health-care systems. And the ultimate goal is to, in a decade or so, make Wisconsin look like La Crosse, with every resident having a plan for death.

“We eventually want everyone to have this conversation,” says Maycroft. “I want to show that this can be done, that it’s something Wisconsin can do and that other medical societies can do. We’re here for Wisconsinites, but we also want to be a national model.”

I was surprised to see that Wisconsin had moved this program forward with little public protest, given the fierce fight over death panels that happened in Washington a few years ago. But even more than that, the thing I found most baffling about the La Crosse model’s growth was that hospitals earn no money from having these conversations.

“We got no reimbursement,” says Hammes of launching the program in La Crosse. “For the hospital, this would lose money.”

“I want to show that this can be done, that it’s something Wisconsin can do and that other medical societies can do”

Whenever doctors do anything — whether it’s a blood test or brain surgery — they charge the patient’s health insurance plan a fee. Doctors, like lawyers, are constantly billing for the time they spend talking to or operating on patients. I’ve written on the health industry for six years now, and I’d never heard of a service that hospitals don’t charge for, like these end-of-life consultations.

Reimbursement would certainly help, Maycroft and others told me. But there’s also a risk that comes with formalizing the program: the vicious debates that happened when the Obama administration proposed paying doctors for this exact type of conversation.

“We haven’t asked for any legislation,” Maycroft says. “The state knows about us, but we’re not asking for any kind of money. We’ve avoided the death panel accusations.”

This makes it easier for programs like his to fly under the radar — but is also a limiting factor for expanding. Not all hospitals will want to do this type of work out of the goodness of their own hearts — and even hospitals that are on board have difficulty committing resources to a program that doesn’t pay.

“The biggest challenge for us is financial,” says Toni Kessler, the ethics manager at Community Care, a hospice provider participating in the Wisconsin program. “I spend a lot of time talking to our finance people, anyone I can get in front of. But it can be a tough case to make when we don’t get reimbursed.”

Minnesota, whose program began five years before Wisconsin’s, made its first request for state money last month, pushing for a bill that would fund the advance directive program.

“The day we introduced our legislation someone else dropped a bill relating to physician-assisted suicide,” says Sue Schettle, executive director of the Twin Cities Medical Society. “And I was thinking, ‘If there’s ever day where this issue would blow up, this was it. I was dreading reading the next day’s newspaper.'”

The explosion never happened. “Maybe it’s our Midwestern nature, that we’re just putting our heads down and getting to work,” Schettle mused to me.

Maycroft thinks the Wisconsin program can go forward for some time without any funding. So far, hospitals have paid his organization money to get trained in end-of-life care conversations, and that has kept the effort afloat.

At the same time, getting insurers and Medicare to reimburse for these conversations remains an important and challenging goal. Maycroft sent me a follow-up email on this point shortly after we talked.

“I’m not sure I expressed well just how much Medicare and insurer reimbursement would help us,” he wrote. “Our participants’ willingness to do this without reimbursement has been impressive, but (and feel free to quote me on this) Medicare reimbursement would make a huge difference. Our participants are doing everything they can, but sustainability of these programs will be a challenge without reimbursement.”

The lack of reimbursement for end-of-life planning suggests a limit to how far the La Crosse model can spread. It currently relies on the willingness of hospitals to donate their time, essentially having doctors volunteer time out of their already busy days.

Going national would almost certainly require Medicare to start paying for these conversations. And maybe, with programs like those in Minnesota and Wisconsin, Washington will begin to get ready.Complete Article HERE!

Most of us would rather not think about what happens to our bodies after death. But that breakdown gives birth to new life in unexpected ways, writes Moheb Costandi.

“It might take a little bit of force to break this up,” says mortician Holly Williams, lifting John’s arm and gently bending it at the fingers, elbow and wrist. “Usually, the fresher a body is, the easier it is for me to work on.”

Williams speaks softly and has a happy-go-lucky demeanour that belies the nature of her work. Raised and now employed at a family-run funeral home in north Texas, she has seen and handled dead bodies on an almost daily basis since childhood. Now 28 years old, she estimates that she has worked on something like 1,000 bodies.

Her work involves collecting recently deceased bodies from the Dallas–Fort Worth area and preparing them for their funeral.

“Most of the people we pick up die in nursing homes,” says Williams, “but sometimes we get people who died of gunshot wounds or in a car wreck. We might get a call to pick up someone who died alone and wasn’t found for days or weeks, and they’ll already be decomposing, which makes my work much harder.”

John had been dead about four hours before his body was brought into the funeral home. He had been relatively healthy for most of his life. He had worked his whole life on the Texas oil fields, a job that kept him physically active and in pretty good shape. He had stopped smoking decades earlier and drank alcohol moderately. Then, one cold January morning, he suffered a massive heart attack at home (apparently triggered by other, unknown, complications), fell to the floor, and died almost immediately. He was just 57 years old.

Now, John lay on Williams’ metal table, his body wrapped in a white linen sheet, cold and stiff to the touch, his skin purplish-grey – telltale signs that the early stages of decomposition were well under way.

Self-digestion

Far from being ‘dead’, a rotting corpse is teeming with life. A growing number of scientists view a rotting corpse as the cornerstone of a vast and complex ecosystem, which emerges soon after death and flourishes and evolves as decomposition proceeds.

Decomposition begins several minutes after death with a process called autolysis, or self-digestion. Soon after the heart stops beating, cells become deprived of oxygen, and their acidity increases as the toxic by-products of chemical reactions begin to accumulate inside them. Enzymes start to digest cell membranes and then leak out as the cells break down. This usually begins in the liver, which is rich in enzymes, and in the brain, which has a high water content. Eventually, though, all other tissues and organs begin to break down in this way. Damaged blood cells begin to spill out of broken vessels and, aided by gravity, settle in the capillaries and small veins, discolouring the skin.

Body temperature also begins to drop, until it has acclimatised to its surroundings. Then, rigor mortis – “the stiffness of death” – sets in, starting in the eyelids, jaw and neck muscles, before working its way into the trunk and then the limbs. In life, muscle cells contract and relax due to the actions of two filamentous proteins (actin and myosin), which slide along each other. After death, the cells are depleted of their energy source and the protein filaments become locked in place. This causes the muscles to become rigid and locks the joints.

During these early stages, the cadaveric ecosystem consists mostly of the bacteria that live in and on the living human body. Our bodies host huge numbers of bacteria; every one of the body’s surfaces and corners provides a habitat for a specialised microbial community. By far the largest of these communities resides in the gut, which is home to trillions of bacteria of hundreds or perhaps thousands of different species.

The gut microbiome is one of the hottest research topics in biology; it’s been linked to roles in human health and a plethora of conditions and diseases, from autism and depression to irritable bowel syndrome and obesity. But we still know little about these microbial passengers. We know even less about what happens to them when we die.

In August 2014, forensic scientist Gulnaz Javan of Alabama State University in Montgomery and her colleagues published the very first study of what they have called the thanatomicrobiome (from thanatos, the Greek word for ‘death’).

“Many of our samples come from criminal cases,” says Javan. “Someone dies by suicide, homicide, drug overdose or traffic accident, and I collect tissue samples from the body. There are ethical issues [because] we need consent.”

Most internal organs are devoid of microbes when we are alive. Soon after death, however, the immune system stops working, leaving them to spread throughout the body freely. This usually begins in the gut, at the junction between the small and large intestines. Left unchecked, our gut bacteria begin to digest the intestines – and then the surrounding tissues – from the inside out, using the chemical cocktail that leaks out of damaged cells as a food source. Then they invade the capillaries of the digestive system and lymph nodes, spreading first to the liver and spleen, then into the heart and brain.

Javan and her team took samples of liver, spleen, brain, heart and blood from 11 cadavers, at between 20 and 240 hours after death. They used two different state-of-the-art DNA sequencing technologies, combined with bioinformatics, to analyse and compare the bacterial content of each sample.

The samples taken from different organs in the same cadaver were very similar to each other but very different from those taken from the same organs in the other bodies. This may be due partly to differences in the composition of the microbiome of each cadaver, or it might be caused by differences in the time elapsed since death. An earlier study of decomposing mice revealed that although the microbiome changes dramatically after death, it does so in a consistent and measurable way. The researchers were able to estimate time of death to within three days of a nearly two-month period.

Javan’s study suggests that this ‘microbial clock’ may be ticking within the decomposing human body, too. It showed that the bacteria reached the liver about 20 hours after death and that it took them at least 58 hours to spread to all the organs from which samples were taken. Thus, after we die, our bacteria may spread through the body in a systematic way, and the timing with which they infiltrate first one internal organ and then another may provide a new way of estimating the amount of time that has elapsed since death.

“Degree of decomposition varies not only from individual to individual but also differs in different body organs,” says Javan, “Spleen, intestine, stomach and pregnant uterus are earlier to decay, but on the other hand kidney, heart and bones are later in the process.” In 2014, Javan and her colleagues secured a US$200,000 grant from the National Science Foundation to investigate further. “We will do next-generation sequencing and bioinformatics to see which organ is best for estimating [time of death] – that’s still unclear,” she says.

One thing that does seem clear, however, is that a different composition of bacteria is associated with different stages of decomposition.

Putrefaction

Scattered among the pine trees in Huntsville, Texas, lie around half a dozen human cadavers in various stages of decay. The two most recently placed bodies are spread-eagled near the centre of the small enclosure with much of their loose, grey-blue mottled skin still intact, their ribcages and pelvic bones visible between slowly putrefying flesh. A few metres away lies another, fully skeletonised, with its black, hardened skin clinging to the bones, as if it were wearing a shiny latex suit and skullcap. Further still, beyond other skeletal remains scattered by vultures, lies a third body within a wood and wire cage. It is nearing the end of the death cycle, partly mummified. Several large, brown mushrooms grow from where an abdomen once was.

For most of us the sight of a rotting corpse is at best unsettling and at worst repulsive and frightening, the stuff of nightmares. But this is everyday for the folks at the Southeast Texas Applied Forensic Science Facility. Opened in 2009, the facility is located within a 247-acre area of National Forest owned by Sam Houston State University (SHSU). Within it, a nine-acre plot of densely wooded land has been sealed off from the wider area and further subdivided, by 10-foot-high green wire fences topped with barbed wire.

In late 2011, SHSU researchers Sibyl Bucheli and Aaron Lynne and their colleagues placed two fresh cadavers here, and left them to decay under natural conditions.

Once self-digestion is under way and bacteria have started to escape from the gastrointestinal tract, putrefaction begins. This is molecular death – the breakdown of soft tissues even further, into gases, liquids and salts. It is already under way at the earlier stages of decomposition but really gets going when anaerobic bacteria get in on the act.

Putrefaction is associated with a marked shift from aerobic bacterial species, which require oxygen to grow, to anaerobic ones, which do not. These then feed on the body’s tissues, fermenting the sugars in them to produce gaseous by-products such as methane, hydrogen sulphide and ammonia, which accumulate within the body, inflating (or ‘bloating’) the abdomen and sometimes other body parts.

This causes further discolouration of the body. As damaged blood cells continue to leak from disintegrating vessels, anaerobic bacteria convert haemoglobin molecules, which once carried oxygen around the body, into sulfhaemoglobin. The presence of this molecule in settled blood gives skin the marbled, greenish-black appearance characteristic of a body undergoing active decomposition.

As the gas pressure continues to build up inside the body, it causes blisters to appear all over the skin surface. This is followed by loosening, and then ‘slippage’, of large sheets of skin, which remain barely attached to the deteriorating frame underneath. Eventually, the gases and liquefied tissues purge from the body, usually leaking from the anus and other orifices and frequently also leaking from ripped skin in other parts of the body. Sometimes, the pressure is so great that the abdomen bursts open.

Bloating is often used as a marker for the transition between early and later stages of decomposition, and another recent study shows that this transition is characterised by a distinct shift in the composition of cadaveric bacteria.

Bucheli and Lynne took samples of bacteria from various parts of the bodies at the beginning and the end of the bloat stage. They then extracted bacterial DNA from the samples and sequenced it.

As an entomologist, Bucheli is mainly interested in the insects that colonise cadavers. She regards a cadaver as a specialised habitat for various necrophagous (or ‘dead-eating’) insect species, some of which see out their entire life cycle in, on and around the body.

Colonisation

When a decomposing body starts to purge, it becomes fully exposed to its surroundings. At this stage, the cadaveric ecosystem really comes into its own: a ‘hub’ for microbes, insects and scavengers.

Two species closely linked with decomposition are blowflies and flesh flies (and their larvae). Cadavers give off a foul, sickly-sweet odour, made up of a complex cocktail of volatile compounds that changes as decomposition progresses. Blowflies detect the smell using specialised receptors on their antennae, then land on the cadaver and lay their eggs in orifices and open wounds.

Each fly deposits around 250 eggs that hatch within 24 hours, giving rise to small first-stage maggots. These feed on the rotting flesh and then moult into larger maggots, which feed for several hours before moulting again. After feeding some more, these yet larger, and now fattened, maggots wriggle away from the body. They then pupate and transform into adult flies, and the cycle repeats until there’s nothing left for them to feed on.

Under the right conditions, an actively decaying body will have large numbers of stage-three maggots feeding on it. This ‘maggot mass’ generates a lot of heat, raising the inside temperature by more than 10°C. Like penguins huddling in the South Pole, individual maggots within the mass are constantly on the move. But whereas penguins huddle to keep warm, maggots in the mass move around to stay cool.

“It’s a double-edged sword,” Bucheli explains, surrounded by large toy insects and a collection of Monster High dolls in her SHSU office. “If you’re always at the edge, you might get eaten by a bird, and if you’re always in the centre, you might get cooked. So they’re constantly moving from the centre to the edges and back.”

The presence of flies attracts predators such as skin beetles, mites, ants, wasps and spiders, which then feed on or parasitise the flies’ eggs and larvae. Vultures and other scavengers, as well as other large meat-eating animals, may also descend upon the body.

In the absence of scavengers, though, the maggots are responsible for removal of the soft tissues. As Carl Linnaeus (who devised the system by which scientists name species) noted in 1767, “three flies could consume a horse cadaver as rapidly as a lion”. Third-stage maggots will move away from a cadaver in large numbers, often following the same route. Their activity is so rigorous that their migration paths may be seen after decomposition is finished, as deep furrows in the soil emanating from the cadaver.

Every species that visits a cadaver has a unique repertoire of gut microbes, and different types of soil are likely to harbour distinct bacterial communities – the composition of which is probably determined by factors such as temperature, moisture, and the soil type and texture.

All these microbes mingle and mix within the cadaveric ecosystem. Flies that land on the cadaver will not only deposit their eggs on it, but will also take up some of the bacteria they find there and leave some of their own. And the liquefied tissues seeping out of the body allow the exchange of bacteria between the cadaver and the soil beneath.

When they take samples from cadavers, Bucheli and Lynne detect bacteria originating from the skin on the body and from the flies and scavengers that visit it, as well as from soil. “When a body purges, the gut bacteria start to come out, and we see a greater proportion of them outside the body,” says Lynne.

Thus, every dead body is likely to have a unique microbiological signature, and this signature may change with time according to the exact conditions of the death scene. A better understanding of the composition of these bacterial communities, the relationships between them and how they influence each other as decomposition proceeds could one day help forensics teams learn more about where, when and how a person died.

For instance, detecting DNA sequences known to be unique to a particular organism or soil type in a cadaver could help crime scene investigators link the body of a murder victim to a particular geographical location or narrow down their search for clues even further, perhaps to a specific field within a given area.

“There have been several court cases where forensic entomology has really stood up and provided important pieces of the puzzle,” says Bucheli, adding that she hopes bacteria might provide additional information and could become another tool to refine time-of-death estimates. “I hope that in about five years we can start using bacterial data in trials,” she says.

What can a fly tell us about time of death? Mo Costandi looks at the emerging field of forensic entomology.

To this end, researchers are busy cataloguing the bacterial species in and on the human body, and studying how bacterial populations differ between individuals. “I would love to have a dataset from life to death,” says Bucheli. “I would love to meet a donor who’d let me take bacterial samples while they’re alive, through their death process and while they decompose.”

Purging

“We’re looking at the purging fluid that comes out of decomposing bodies,” says Daniel Wescott, director of the Forensic Anthropology Center at Texas State University in San Marcos.

Wescott, an anthropologist specialising in skull structure, is using a micro-CT scanner to analyse the microscopic structure of the bones brought back from the body farm. He also collaborates with entomologists and microbiologists – including Javan, who has been busy analysing samples of cadaver soil collected from the San Marcos facility – as well as computer engineers and a pilot, who operate a drone that takes aerial photographs of the facility.

“I was reading an article about drones flying over crop fields, looking at which ones would be best to plant in,” he says. “They were looking at near-infrared, and organically rich soils were a darker colour than the others. I thought if they can do that, then maybe we can pick up these little circles.”

Those “little circles” are cadaver decomposition islands. A decomposing body significantly alters the chemistry of the soil beneath it, causing changes that may persist for years. Purging – the seeping of broken-down materials out of what’s left of the body – releases nutrients into the underlying soil, and maggot migration transfers much of the energy in a body to the wider environment. Eventually, the whole process creates a ‘cadaver decomposition island’, a highly concentrated area of organically rich soil. As well as releasing nutrients into the wider ecosystem, this attracts other organic materials, such as dead insects and faecal matter from larger animals.

According to one estimate, an average human body consists of 50–75 per cent water, and every kilogram of dry body mass eventually releases 32 g of nitrogen, 10 g of phosphorous, 4 g of potassium and 1 g of magnesium into the soil. Initially, it kills off some of the underlying and surrounding vegetation, possibly because of nitrogen toxicity or because of antibiotics found in the body, which are secreted by insect larvae as they feed on the flesh. Ultimately, though, decomposition is beneficial for the surrounding ecosystem.

The microbial biomass within the cadaver decomposition island is greater than in other nearby areas. Nematode worms, associated with decay and drawn to the seeping nutrients, become more abundant, and plant life becomes more diverse. Further research into how decomposing bodies alter the ecology of their surroundings may provide a new way of finding murder victims whose bodies have been buried in shallow graves.

Grave soil analysis may also provide another possible way of estimating time of death. A 2008 study of the biochemical changes that take place in a cadaver decomposition island showed that the soil concentration of lipid-phosphorous leaking from a cadaver peaks at around 40 days after death, whereas those of nitrogen and extractable phosphorous peak at 72 and 100 days, respectively. With a more detailed understanding of these processes, analyses of grave soil biochemistry could one day help forensic researchers to estimate how long ago a body was placed in a hidden grave.

Burial

In the relentless dry heat of a Texan summer, a body left to the elements will mummify rather than decompose fully. The skin will quickly lose all of its moisture, so that it remains clinging to the bones when the process is complete.

The speed of the chemical reactions involved doubles with every 10°C rise in temperature, so a cadaver will reach an advanced stage of decomposition after 16 days at an average daily temperature of 25°C. By then, most of the flesh has been removed from the body, and so the mass migration of maggots away from the carcass can begin.

The ancient Egyptians learned inadvertently how the environment affects decomposition. In the predynastic period, before they started building elaborate coffins and tombs, they wrapped their dead in linen and buried them directly in the sand. The heat inhibited the activity of microbes, while burial prevented insects from reaching the bodies, and so they were extremely well preserved. Later on, they began building elaborate tombs for the dead, in order to provide even better for their afterlife, but this had the opposite of the intended effect –separating the body from the sand actually hastened decomposition. And so they invented embalming and mummification.

Embalming involves treating the body with chemicals that slow down the decomposition process. The ancient Egyptian embalmer would first wash the body of the deceased with palm wine and Nile water, remove most of the internal organs through an incision made down the left-hand side, and pack it with natron (a naturally-occurring salt mixture found throughout the Nile Valley). He would use a long hook to pull the brain out through the nostrils, then cover the entire body with natron and leave it to dry for 40 days. Initially, the dried organs were placed into canopic jars that were buried alongside the body; later, they were wrapped in linen and returned to the body. Finally, the body itself was wrapped in multiple layers of linen, in preparation for burial. Morticians study the ancient Egyptian embalming method to this day.

Back at the funeral home, Holly Williams performs something similar so that family and friends can view their departed loved one at the funeral as they once were, rather than as they now are. For victims of trauma and violent deaths, this can involve extensive facial reconstruction.

Living in a small town, Williams has worked on many people she knew or grew up with – friends who overdosed, committed suicide or died texting at the wheel. When her mother died four years ago, Williams did some work on her, too, adding the final touches by making up her face: “I always did her hair and make-up when she was alive, so I knew how to do it just right.”

She transfers John to the prep table, removes his clothes and positions him, then takes several small bottles of embalming fluid from a wall cupboard. The fluid contains a mixture of formaldehyde, methanol and other solvents; it temporarily preserves the body’s tissues by linking cellular proteins to each other and ‘fixing’ them into place. The fluid kills bacteria and prevents them from breaking down the proteins and using them as a food source.

Williams pours the bottles’ contents into the embalming machine. The fluid comes in an array of colours, each matching a different skin tone. Williams wipes his body with a wet sponge and makes a diagonal incision just above his left collarbone. She ‘raises’ the carotid artery and subclavian vein from the neck, ties them off with pieces of string, then pushes a cannula (thin tube) into the artery and small tweezers into the vein to open up the vessels.

Next, she switches the machine on, pumping embalming fluid into the carotid artery and around John’s body. As the fluid goes in, blood pours out of the incision, flowing down along the guttered edges of the sloped metal table and into a large sink. Meanwhile, she picks up one of his limbs to massage it gently. “It takes about an hour to remove all the blood from an average-sized person and replace it with embalming fluid,” Williams says. “Blood clots can slow it down, so massaging breaks them up and helps the flow of the embalming fluid.”

Once all the blood has been replaced, she pushes an aspirator into John’s abdomen and sucks the fluids out of the body cavity, together with any urine and faeces that might still be in there. Finally, she sews up the incisions, wipes the body down a second time, sets the facial features and re-dresses it. John is now ready for his funeral.

Embalmed bodies do eventually decompose. Exactly when, and how long it takes, depends largely on how the embalming was done, the type of casket in which the body is placed and how it is buried. Bodies are, after all, merely forms of energy, trapped in lumps of matter waiting to be released into the wider universe.

According to the laws of thermodynamics, energy cannot be created or destroyed, only converted from one form to another. In other words: things fall apart, converting their mass to energy while doing so. Decomposition is one final, morbid reminder that all matter in the universe must follow these fundamental laws. It breaks us down, equilibrating our bodily matter with its surroundings, and recycling it so that other living things can put it to use.

Stephanie Packer was 29 when she found out she had a terminal lung disease.

That’s the same age as Brittany Maynard, who last year was diagnosed with terminal brain cancer. Last fall, Maynard, of Northern California, opted to end her life with the help of a doctor in Oregon, where physician-assisted suicide is legal.

Maynard’s story continues to garner support for right-to-die legislation moving through legislatures in California and several other states. Now, Packer, another young California woman, is stepping up to share her story, but she wants people to draw a different conclusion.

On a recent spring afternoon, Packer, 32, is in her kitchen, preparing lunch with her four children.

“Do you want to help?” she asks the eager crowd of siblings gathered tightly around her at the stovetop.

“Yeah!” yells 5-year-old Savannah.

“I do!” says Jacob, who is 8.

Calmly managing four kids as each vies for the chance to help make chicken salad sandwiches can be trying, but Packer cherishes these moments.

In 2012, after suffering a series of debilitating lung infections, she went to a doctor who diagnosed her with scleroderma. The autoimmune disease causes hardening of the skin and (in about one-third of cases) other organs. The doctor told Packer that it had settled in her lungs.

“And I said, ‘OK, what does this mean for me?’ ” she recalls. “And he said, ‘Well, with this condition you have about three years left to live.’ ”

Packer is on oxygen full time and she takes a slew of medications.

She says she has been diagnosed with a series of conditions linked to or associated with scleroderma, including lupus, gastroparesis, Raynaud’s phenomenon, interstitial cystitis and trigeminal neuralgia.

Packer’s various maladies have her in constant, sometimes excruciating pain, she says. She also can’t digest food properly and feels extremely fatigued almost all the time.

Some days, Packer says, are good. Others are marked by low energy and pain that only sleep can relieve.

“For my kids, I need to be able to control the pain because that’s what concerns them the most,” she says.

But Packer says physician-assisted suicide isn’t something she is considering.

“Wanting the pain to stop, wanting the humiliating side effects to go away — that’s absolutely natural,” Packer says. “I absolutely have been there and I still get there some days. But I don’t get to that point of wanting to end it all, because I have been given the tools to understand that today is a horrible day, but tomorrow doesn’t have to be.”

She and husband Brian, 36, are devout Catholics. They agree with their church that doctors should never hasten death.

“We’re a faith-based family,” he says. “God put us here on earth and only God can take us away. And he has a master plan for us, and if suffering is part of that plan, which it seems to be, then so be it.”

They also believe if California legislation called SB 128 passes, it would create the potential for abuse. Pressure to end one’s life, they fear, could become a dangerous norm, especially in a world defined by high-cost medical care.

“Death can be beautiful and peaceful,” she says. “It’s a natural process that should be allowed to happen on its own.” Even, she says, when it poses uncomfortable challenges.

Brian has traded his full-time job at a lumber company for weekend handyman work so he can care for Stephanie and the children. The family downsized, moving into a two-bedroom apartment they share with their dog and two pet geckos.

Brian says life is good.

“I have four beautiful children. I get to spend so much more time with them than most head of households,” he says. “I get to spend more time with my wife than most husbands do.”

And it’s that kind of support — from family, friends and people in her community — that Stephanie says keeps her living in gratitude, even as she struggles with her terminal illness and the realization that she will not be there to see her children grow up.

“I know eventually that my lungs are going to give out, which will make my heart give out,” she says. “And I know that’s going to happen sooner than I would like — sooner than my family would like. But I’m not making that my focus. My focus is today.”

Stephanie says she is hoping for a double lung transplant, which could give her a few more years. In the meantime, this month marks three years since her doctor gave her three years to live. So every day, she says, is a blessing.Complete Article HERE!

Less than a third of people have discussed what they want to happen at the end of life. Just four per cent have written advance care plans for when they are dying. Yet more than two thirds of people questioned say they are comfortable talking about death.

Even older people are unlikely to discuss what will happen at the end of their lives.

The NatCen survey of more than 1,300 people showed seven in ten want to die at home. This is at a time when six in ten people die in hospital.

The research, commissioned by Dying Matters Coalition, examines public attitudes to issues around death, dying and bereavement.

While people have strong views about the end of life, they are still unlikely to have discussed their own death. This was mainly because people felt death was a long way off or that they were too young to discuss it. Nearly one in ten of people aged 65 to 74 years old believed they were too young to discuss dying.

Three in ten people had never seen a dead body. Just one per cent of the sample said they would go to a minister, pastor or vicar for information about planning the end of life. Most people’s preferred choice for seeking information was a friend or family member, or their GP.

This was despite the fact that nearly seven in ten of the respondents described themselves as Christian. Nearly two in ten said they were atheist or had no religion.

Professor Mayur Lakhani, chair of Dying Matters, said: “As a practising GP, I know that many people feel frightened to talk about death for fear of upsetting the person they love. However, it is essential that people do not leave it until it is too late. Planning for needs and wishes helps you to be in control, and it helps those we leave behind.”

One carer said: “It’s not easy to talk about end of life issues, but it’s important to do. Now that we’ve put our affairs in order and are talking about what we want, we can ‘put that in a box’ as it were, and get on with living one day at a time, cherishing each day together, as I know it’s going to end one day.”

A bereaved widow said: “If you talk about dying, you can say everything you want or need to. There are no regrets.”Complete Article HERE!